Concurrent Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair with Fundoplication and Robotic-Assisted Video-Thoracoscopic Right Upper Lobectomy for Lung Cancer

Eric M Toloza, MD, PhD1, David M Straughan, MD2, Jonathan Hernandez, MD2, Joseph R Garrett, ARNPC, MPH1, Maki Yamamoto, MD2, Tannous Fakhry, MD2, Carla C Moodie, PAC1, Kenneth L Meredith, MD1. 1Moffitt Cancer Center, 2University of South Florida Morsani College of Medicine

Introduction:  Stage-3A non-small cell lung cancer (NSCLC) is generally treated with induction chemotherapy and radiation therapy (RT), followed by surgery.  Paraesophageal hiatal hernia complicated by gastric volvulus should be surgically repaired.  We report the first known robotic-assisted paraesophageal hiatal hernia repair concurrent with robotic-assisted pulmonary lobectomy for lung cancer.

Case Report:  A 64-year-old diabetic, with 160-pack-year tobacco history, had positron-emission tomography and computerized tomography demonstrating 6.3-cm right upper lobe (RUL) lung mass, with hilar and subcarinal lymphadenopathy, but no distant metastasis.  Needle biopsies of RUL lung mass and para-azygos lymph node (LN) each revealed CK7-positive/TTF1-positive adenocarcinoma, confirming stage-3A NSCLC.  Gastric volvulus, complicating his paraesophageal hernia, was treated non-surgically but delayed induction chemotherapy.  He eventually underwent carboplatin/Taxol chemotherapy x7 weeks with 500-Gy RT, decreasing the right NSCLC to 5.4 cm.  He then underwent laparoscopic paraesophageal hernia reduction and hernia sac resection, with robotic-assisted laparoscopic crurapexy and Nissen fundoplication.  Concurrently, he underwent robotic-assisted video-thoracoscopic RUL lobectomy, with mediastinal LN dissection, and right middle and right lower lobe wedge resections x3, performed in left lateral decubitus via 3 thoracoscopy ports.  Total operative (skin-to-skin) time was 545 min, including 341 min for paraesophageal hernia repair and 204 min for lung resection.  Total intraoperative estimated blood loss was 360 mL.  Postoperative complications included pulmonary embolus on postoperative day (POD)#3; atrial fibrillation with rapid ventricular rate on POD#5; dysphagia requiring repeated swallow evaluations and slow advancement to regular diet; prolonged air leak; and enlarging right pneumothorax (PTX) after chest tube removal, requiring CT-guided pleural pigtail catheter.  Pathology revealed minimal residual poorly-differentiated carcinoma, with therapy-related necrosis and fibrosis involving 99% of 4-cm tumor, and 0 of 13 interlobar, hilar, and mediastinal LNs demonstrating metastatic carcinoma.  On POD#17, he was discharged with therapeutic subcutaneous dalteparin and pigtail catheter, connected to Pneumostat valve and removed on POD#26.  He was readmitted on POD#32 for increasing dyspnea from recurrent right PTX requiring CT-guided pleural pigtail catheter and bedside transcatheter doxycycline pleurodesis.  Air leak resolved, and pigtail catheter was removed on POD#37.  Patient then underwent consolidation cisplatin/Taxol chemotherapy, which was discontinued due to nausea, emesis, persistent diarrhea, and prolonged arthralgias.

Discussion:  Patients with comorbidities tolerate minimally invasive surgery better than open surgery.  Although our patient’s diabetes, 160-pk-yr tobacco history, and induction chemotherapy and RT likely contributed to his complicated postoperative course, he successfully underwent the first reported concurrent robotic-assisted paraesophageal hernia repair with Nissen fundoplication and robotic-assisted RUL lobectomy for lung cancer.

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